Episode 055: Breast Cancer Series, Pt. 4-Surgical management for breast cancer
Surgery plays a pivotal role in the management of breast cancer, particularly in early stages of disease. This week, we are joined by special guest Dr. Carla Fisher, Associate Professor and Medical Director of Breast Surgical Oncology at Indiana University School of Medicine!
Factors to consider for patients who wish to undergo breast conserving surgery
To determine if a patient is a candidate for breast conserving surgery, several factors are considered including the size of the tumor, quality of the calcifications, tumor to breast ratio, quality of the imaging, and patient preference.
When is a breast MRI indicated?
If imaging is suboptimal or if the patient is younger than 40 (dense breasts), consider breast MRI to help form the surgical plan.
For patients without palpable lymphadenopathy, when is additional imaging indicated to rule out node positive disease?
There are no set criteria for axillary ultrasound but consider it results will affect the recommendation for neoadjuvant chemotherapy.
Also note that if a breast MRI is planned, it will evaluate the axilla appropriately.
Placement of surgical clips
If a patient is node positive, clips help the surgeon make sure they have removed the node.
Clips can also help medical oncologists determine if they have achieved a pathologic complete response.
How long after neoadjuvant therapy should surgery be delayed?
Optimally, a surgeon will operate 4-6 weeks after cytotoxic chemotherapy.
What is a “modified radical mastecomy” and how does this compare to the “halsted” method?
Modified radical mastectomy removes the entire breast, skin, areola, nipple, and most lymph nodes and is still performed commonly.
The Halstead mastectomy, which removes a significant amount of the pectoralis muscle and includes an extensive lymph node dissection, is no longer performed.
How long after surgery should we wait to adminster adjuvant therapy?
The time frame from surgery to adjuvant therapy depends on the type of breast surgery performed.
Systemic chemotherapy can usually be given 2-3 weeks following a lumpectomy.
Anti-HER2 treatment can be continued throughout the surgical period.
Radiation therapy can be performed usually 3-5 weeks following surgery.
What is a sentinal lymph node biopsy?
The NSABP B-32 trial found that patients with clinically node negative breast cancer who had a sentinel lymph node biopsy (SLNB) did just as well as patients who received upfront axillary dissection.
The sentinel lymph node is the one the cancer will likely spread to first.
Surgeons inject patients’ lymphatic system with dye and 2-5 lymph nodes are sent to pathology intraoperatively.
If those nodes are negative for cancer, there is a low chance that there is additional cancer in further nodes.
What does “no ink on margin” during a lumpectomy entail?
Surgeons can visualize grossly negative margins, but “no ink on the margin” is a microscopic finding on pathology.
Breast reconstruction after surgery
Breast reconstruction following a mastectomy can be implant based or tissue based, which uses fat from the abdomen or muscle from the back.
When a skin or nipple sparing mastectomy is preformed, a tissue expander is sometimes placed on top of the pectoralis muscle as a placeholder for definitive breast reconstruction.
When should a prophylactic contralateral mastectomy be performed?
Performing a prophylactic contralateral mastectomy is a nuanced decision.
There is ~0.5-1% risk per year of developing an additional breast cancer in the contralateral breast, but there is no proven survival benefit of prophylactic mastectomy over yearly screening.
Role of surgery in inflammatory breast cancer
Timing of mastectomy for inflammatory breast cancer is the same as any patient getting neoadjuvant chemotherapy.
A patient with inflammatory, triple negative breast cancer needs axillary lymph node dissection and adjuvant radiation therapy by current guidelines.
In these patients, If there is not a response to neoadjuvant chemotherapy, surgery would likely not benefit the patient.
Palliative surgery or radiation can be considered in rare cases including a foul smelling or bleeding mass that is causing discomfort or in disease where the metastases seem to be stable, but the breast mass is enlarging.
About our guest!
Dr. Carla Fisher, MD, MBA, FACS is an Associate Professor of Surgery and Medical Director of Breast Surgery at the Indiana University School of Medicine. She received her medical degree from the University of Pennsylvania, after which she completed her General Surgery residency at the Medical University of South Carolina. She then completed a fellowship in Breast Surgical Oncology at Washington University School of Medicine.
References:
https://pubmed.ncbi.nlm.nih.gov/20863759/: NSABP B-32 study which compared outcomes between sentinel lymph node dissection compared to axiallry lymph node dissections in clinically node negative patients
The crew behind the magic:
Show outline: Vivek Patel
Production and hosts: Ronak Mistry, Vivek Patel, Dan Hausrath
Editing: Resonate Recordings
Shownotes: Madeline Fitzpatrick, Ronak Mistry
Social media management: Ronak Mistry
IMPORTANT REMINDERS FROM EPISODE 054!
Important surgical terminology:
Lumpectomy aka breast conservation surgery aka partial mastectomy: Only the mass and some surrounding tissue is removed
Mastectomy: Whole breast is removed
Margins:
When performing lumpectomy, the surgeon will use ink to draw a circle around the tumor + some adjacent healthy tissue. When the pathologist looks at the tissue under microscope, we are hoping to see “no ink on tumor” meaning that there is healthy issue surrounding the tumor that has been removed.
If there is tumor at the ink line, double risk of recurrence
Clear margins has the lowest chance of recurrence
For invasive cancer: Society of Surgical Oncology and American Society for Radiation Oncology recommend “no ink on tumor” based on results of a large met-analysis. Essentially, they are saying that wider margins (for instance >2mm) is no different in terms of outcomes than narrower margins
For DCIS: SSO and ASTRO recommend 2mm margins also based on meta-analysis
General approach to TNM staging
Think about it as dollar bill amounts → similar to the mnemonic for the common pathway of the coagulation cascade
Think 1 dollar, 2 dollar (don’t forget we used to have the 2 dollar bill), and 5 dollar bill
T1C = > 1 cm
T2 = > 2 cm
T3 = > 5 cm
Nodal disease → the axilla is key
Mobile axillary nodes palpable = N1
Fixed or matted axillary nodes palpable = N2
Internal mammary nodes (IMN) without axillary nodes = N2 → think inner quadrant of breast → N2 because these are central nodes
Everything else = N3
